- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.18 / $1,713.51 / $2,540.78
| Professional | | $1,657.18 | $1,713.51 | $2,540.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,890.00 / $5,868.00 / $9,078.00
| Professional | | $4,890.00 | $5,868.00 | $9,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.48 / $3,103.31 / $4,395.35
| Professional | | $1,920.48 | $3,103.31 | $4,395.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.08 / $3,487.79 / $7,117.45
| Professional | | $1,941.08 | $3,487.79 | $7,117.45 |